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CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  institute  for  Historical  IMicroreproductions  /  Institut  Canadian  de  microreproductions  historiques 


> 


Technical  and  Bibliographic  Notes/Nc  :es  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  method  of  filming,  are  checked  below. 


0 


D 


D 


D 
D 


n 


n 


Coloured  covers/ 
Couverture  de  couleur 


I      I    Covers  damaged/ 


Couverture  endommagde 


Covers  restored  and/or  laminated/ 
Couverture  restaur6e  et/ou  pellicul^e 


I      I    Cover  title  missing/ 


Le  titre  de  couverture  manque 


I      I    Coloured  maps/ 


Cartes  g6ographiques  en  couleur 


Coloured  ink  (i.e.  other  than  blua  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 


I      I    Coloured  plates  and/or  illustrations/ 


Planches  et/ou  illustratians  en  couleur 

Bound  with  other  material/ 
Reli6  avec  d'autres  documents 

Tight  binding  rray  cause  shadows  or  distortion 
along  interior  margin/ 

Lareliure  serr6e  peut  causer  de  I'ombre  ou  de  la 
distortion  le  long  de  la  marge  intdrieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajout6es 
lors  d'une  restauration  apparaissent  dans  le  texte, 
mais,  torsque  cela  itait  possible,  ces  pages  n'ont 
pas  4t6  filmdes. 

Additional  comments:/ 
Commentaires  suppl6mentaires; 


L'Institut  a  microfilm^  le  meilleur  exemplaire 
qu'il  lui  a  6t6  possible  de  se  procurer.  Les  details 
de  cet  exemplaire  qui  sont  peut-dtre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  m6thode  normale  de  filmage 
sont  indiquds  ci-dessous. 


I      I    Coloured  pages/ 


Pages  de  couleur 

Pages  damaged/ 
Pages  endommagdes 

Pages  restored  and/or  laminated/ 
Pages  restaurdes  et/ou  pellicul^es 

Pages  discoloured,  stained  or  foxed/ 
Pages  d6color6es,  tachetdes  ou  piqu^es 

Pages  detached/ 
Pages  d6tach6es 


v/ 


Showthrough/ 
Transparence 


I      I    Quality  of  print  varies/ 


Qualitd  inigale  de  I'impression 

Includes  supplementary  material/ 
Comprend  du  materiel  supplementaire 

Only  edition  available/ 
Seule  Edition  disponible 


D 


Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  6t6  filmdes  d  nouveau  de  facon  i 
obtenir  la  meilleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film6  au  taux  de  reduction  indiqud  ci-dessous. 


1QX 

14X 

1SX 

22X 

26X 

30X 

y 

12X 

16K 

20X 

24X 

28X 

32X 

The  copy  filmed  here  has  been  reproduced  thank* 
to  the  generosity  of: 

IVIedical  Library 
IVIcGill  University 
Montreal 

The  Images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  In  keeping  with  the 
filming  contract  specifications. 


L'exemplaire  fllmA  fut  reproduit  grAce  d  la 
ginirociti  de: 

Medical  Library 
McGill  University 
Montreal 

Lee  imsges  suivantes  ont  itA  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettet*  de  l'exemplaire  film*,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimte  sont  filmte  en  commen^ant 
par  le  premier  plat  et  en  tarminant  soit  par  la 
derniire  page  qui  comporta  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  salon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  filmte  en  commenpant  par  la 
promidre  page  qui  comporta  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  derniAre  page  qui  comporte  une  telle 
empreinte. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  —»■(  meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 


Un  dee  symboles  sulvants  apparaftra  sur  la 
dernlAre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbols  -^i*>  signifle  "A  SUIVRE",  le 
symbols  V  signifle  "FIN". 


Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  cartee.  planches,  tableaux,  etc.,  peuvent  Atre 
fllmte  A  dee  taux  de  reduction  diff Arents. 
Lorsquc  le  document  est  trop  grand  pour  Atre 
reproduit  en  un  seul  cllchA,  11  est  filmA  A  partir 
de  "angle  supArleur  gauche,  de  gauche  A  droite, 
et  de  haut  en  bee,  en  prenant  le  nombre 
d'Images  n6cessaire.  Les  diagrammes  suivants 
illustrent  la  mithode. 


1 

2 

3 

1 

2 

3 

4 

5 

6 

I 


/«« 


PRIMARY 


CANCER  [Encephaloid]  OF  THE  KIDNET 


DURING    CPIILDHOOD. 


BY 


T.  JOHNSON  ALLOWAY,  M.l),,  L.R  C.S.  and  P.,  Edinburgh, 

Consultinar  Pln'sician  Jlontreal  Dispensary ;  AtteiuliiK,'  Physician  Department  for 
>K  ^.^jjgg^  ^f  Women,  West  End  Free  Dispensary,  Montreal. 


Reprinted  from  The  American  Journal  of  Obstetrics  and  Diseases 

OF  AVOMKN  AND  CHILDREN,  Vul  XVL,  Nos.  VIII.  &  IX.,    1883. 


NEW  YORK : 

\VM    WOOD  &  CO.,  PUBLISHERS,  ,50  &  58   LAFAYETTE  PLACE. 


Looo. 


CANCEl 


T.  JOHNI 

Consultinj 


Reprinted , 
OF  W( 


WM    WO 


PRIMARY 


CANCER  [ENCEPHALOIDJ  OF  THE  KIDNEY 


DURING    CPIILDHOOD. 


BY 


T.  JOHNSON  ALLOWAY,  M.D.,  L.R.C.S.  and  P.,  Edinburgh, 

Consulting  Physician  Montreal  Dispensary;  Attending  Piiysician  Department  for 
Diseases  of  Women,  West  End  Free  Dispensary,  Montreal. 


Reprinted  from  The  American  Journal  of  Obstetrics  and  Diseases 
OF  Women  and  Children,  Vol.  XVI.,  Nos.  VIII.  &  IX.,  1883. 


NEW  YORK : 
WM    WOOD  &  CO.,  PUBLISHERS,  56  &  58   LAFAYETTE  PLACE. 

,1883, 


PRIMARY  CANCER  (Encephaloid)  OF  THE  KIDNEY 


DURING    CHILDHOOD. 


The  following  case  of  cancer  of  the  right  kidney  has  been 
of  some  interest  to  me  from  its  extreme  rarity  in  childhood, 
and  it  may  also  be  interesting,  on  that  account,  to  others. 

Ellen  W.,  aged  five  years,  is  of  English  parentage.  Both 
father  and  mother  are  vigorous  and  have  always  enjoyed  good 
health.  Upon  careful  inqun-y,  however,  it  appears  that  a  paternal 
aunt  of  the  patient,  when  about  six  years  of  age,  caused  con- 
siderable interest  to  be  manifested  in  her  by  several  prominent 
London  physicians  concerning  the  growth  of  a  tumor  in  her  right 
side,  and  that,  although  she  had  visited  several  iiospitals  in  tliat 
great  metropolis,  the  parents  could  not  obtain  a  definite  diag- 
nostic opinion  concerning  its  precise  nature.  The  tumor,  how- 
ever, is  said  to  have  disappeared  after  lasting  about  two  years, 
although  it  had  in  thai-  period  of  time  obtained  such  a  size  as  to 
cause  quite  a  deformity,  which  was  apparent  in  a  photograph 
submitted  to  me.  Further  than  this,  there  is  a  record  of  an  ex- 
cellent family  history  on  both  mother's  and  father's  side.  My 
patient  was  the  second  child  in  a  family  of  three,  and  has  always 
been  in  good  health,  with  the  exoeption  of  a  rather  severe  attack 
of  entero-colitis  in  the  hot  summer  of  1879,  and,  about  a  year 
ago,  of  rtu  attack  of  remittent  fever,  which  lasted  about  three 
weeks,  and  was  accofupaiiied  ivith  diarrhea.  She  never  had 
scarlatina. 

The  first  manifestation  of  her  recent  illness  occurred  last  De- 
cember (1882),  in  the  appearance  of  "  a  lump  on  her  right  side," 
as  her  father  expressed  it.  He  stated  that  the  child  was  not  sick, 
but  that  he  felt  anxious  about  this  lump,  as  she  had  fallen  down 
stairs,  three  months  previous,  and  had  struck  the  very  side  in 
question  against  an  upright  post  during  her  descent.     She  com- 


4         Alloway  :  Primavt/  Cancer  of  the  Kidney. 

l»liiinu(l  iit  the  time  of  tlic  iicciileut,  of  nothing  njorc  tlian  uhiUlrcn 
uauiillv  do  undor  such  circunistiuices,  and  it  was  only  recalled  to 
mind  "hy  the  uppearanco  of  the  pivsont  tumor  in  the  right  side. 

I'livsiciil  examination  revealed  an  ovoid  tumor  extending  from 
the  lower  margin  of  the  liver  to  within  an  inch  of  the  crest  of 
ilium.  This  tumor  occupied  such  a  position  that,  if  a  lateral- 
median  section  of  the  body  were  made,  the  line  of  section  would 
l)as8  half  an  inch  liehind  ihe  ))osterior  margin  of  the  tumor.  It 
was  very  hard  and  movable  both  by  the  hand,  and  by  the  action  of 
the  diaphragm  during  respiration. 


Gentle  manipulation  caused  no  pain  whatever.  At  this  time, 
the  tumor  could  be  grasped  in  its  middle  with  fingers  and  thumb, 
and  lifted  and  moved  about  quite  freely  without  pain  or  incon- 
venience to  the  little  patient.  Percussion  gave  a  continuous  dull 
note  from  the  upper  margin  of  the  liver  to  the  lower  point  of  tumor, 
and  from  this  it  was  concluded  that  close  adhesions  existed  be- 
tween it  and  the  lower  margin  of  liver.  The  patient  was  ap- 
parently in  good  health  ;  the  excretory  organs  performed  their 
respective  functions  in  a  normal  way.  The  urine  was  carefully 
examined  with  negative  results.     Her  appetite  was  good.     She 


Alloway:  Pn'mirij  Cancer  of  the  Kidneij. 


B!o|»t  well.  Her  skin  was  ck'iir,  iind  hIic  liiul  tlio  appoaruncc  of  :i 
plump  woll-noiirislit'd  cliild.  Slio  would  play  and  romp  altout  as 
usual  vvitli  oilier  children.  Towards  oveninji;,  she  would  com- 
plain slightly  to  her  inollior  of  cramps  or  "  pains  in  her  hcUy." 

Jan.  11th.  8hw  patient  again.  Tumor  increasing  in  size, 
chiefly  towards  the  middle  line  of  alxlomen,  and  downwards 
towunl  ilium.  I'atient  not  (piite  so  lively.  She  would  cojnplain 
suddenly  of  pain  at  play,  making  her  peevish.  Ap|)etite  still  good, 
nutrition  good,  bowels  regular,  and  urine  normal. 

Jan.  'Z'ZA,  Found  a  distinct  systolic;  bruit,  heard  loudest  over 
maximum  elevation  of  tumor,  gradually  fading  in  intensity  poste- 
riorly toward  the  spine,  and  anteriorly  toward  the  epigastrium. 
In  both  of  these  situations,  it  was  j)lainly  audible,  but  had  a  distiinb 
character,  while  over  point  of  greatest  elevation  of  growth  it  ap- 
])eared  as  if  quite  near  the  surface,  'i'hc  heart  was  now  slightly 
displaced  ujiward  and  to  the  left.  Pulse  increased  slightly  iu 
rapidity.     Temperature  nornnd.     Urine  still  normal. 

Jan.  26th.  Dr.  Kaddicli  saw  the  patient  with  me  to-day.  'i'lio 
growth  was  much  increased  in  size  since  last  visit,  and  a  decided 
feeling  of  fluctuation  was  now  ((uite  evident  throughout  the 
entire  growth.  At  this  time,  there  was  a  general  enlargement 
of  the  whole  abdomen  becoming  apparent.  The  arterial  bruit  so 
distinctly  heard  the  week  previous  is  no  less  distinct,  and  is  now 
distant  in  character.  The  patii-nt  is  beginning  to  show  signs  of 
emaciation.  There  is  now  noticed  a  prominence  or  bulging  on 
the  left  side  of  the  vertebral  column  at  about  the  level  of  the  lirst, 
second,  and  third  b.nnbar  vertebrre.  This  was  thought  to  be  due 
to  involvement  of  other  postiieritoneal  glands  of  that  side. 

Feb.  1st.  Dr.  I{.  P.  Howard  saw  the  case  with  me,  and  after 
a  careful  examination  agreed  with  us  in  inclining  towards  the  diag- 
nosis of  encephaloid  cancer,  as  far  as  it  was  possible  to  judge  at 
the  present  existing  stage  of  the  disease.  The  tumor  now  seemed 
to  increase  in  almost  every  direction,  and  es[)ecially  so  toward 
the  epigastrium,  where  a  decided  ])romincnce  with  skin  tension 
was  apparent.  The  whole  abdominal  contents  seemed  as  if  in 
one  great  mass  and  moved  together.  There  was  no  tympanitic 
note  on  percussion  to  bo  obtained,  except  along  the  anterior 
axillary  line  of  leftside;  all  to  the  right  of  this  was  of  wooden  dul- 
ness.  There  is  very  little  pain  or  annoyance  caused  by  examina- 
tions. She  can  stand  up  with  assistance,  ])ut  cannot  walk  any 
longer  with  comfort.  She  has  to  be  carried  about.  Heart  is  con- 
siderably displaced  upwards,  and  to  the  left  side,  pulse  very 
rai)id.  Prominence  of  left  side  behind  is  increasing.  Bowels 
move  once  a  day,  and  urine  normal.  The  bruit  in  tumor  can  no 
longer  be  heard  at  any  point. 

February  5tli.  Respiration,  34;  pulse,  l"-iO;  temperature  nor- 
mal.    Measurements  of  abdomen  were  as  follows: 

At  nipple 3o^  inches. 

Xi))hoid  cartilage 22         " 

Eighth  cartilage 23^       " 

Maximum  elevation 24         " 


6 


Alloway  :   Prlimo'ij  Cancel'  of  the  Ki<huy. 


Unibilicn8. , 'i'\    inchoa. 

Extreme  latoriil  l('ii;j;tli  of  tiinior 'r\       " 

Tumor  cxtiMids  lo  loft  of  lunliiliciis.  . .  .     'i,         " 
Apox  of  liciiit-hcat  at-  fourth   iiiti  THpacc,  oiio-lialf  an  iiu!li  out- 
eiilc  left  »ij)i»lu.     Sii|)i'rHcial  veins  very  iiromiiieiit  on  surface  of 
ulxloiuen. 

February  22(1.     Measured  at 

>iil)l)le 21  J  iiiclios. 

Xiplioid  cartilage 'Z'.\         " 

Eighth  rib 24        " 

Maximum  elevation 2(il       '' 

Unil)ili(:uH 2(;         '• 

Apex  heart-beat  one  incii  outside  left  nipple  and  oiu'-f|iuirtpr 
inch  below  level  of  it.  Kespii'ation  auilible  behind  no  lower 
thiiii  oiu'-(pi;uier  of  an  inch  below  iiifei'ior  angle  of  scapula. 

Patient  becoming  very  restless  at  night,  and  complains  of  sore- 
ness in  front  when  lifted.  Pulse  rapid;  tcmperatuie  nornnil. 
Bowels  very  much  constipated,  moving  only  once  every  four 
or  live  days.     No  jaunilice. 

March  5th.  J'atient unable  tol  eave  cot.  She  is  much  emaci- 
ated. J'ulse  lo-lr.  Diarrhea  set  in  last  night.  Urinates  very 
fre(|uently,  passing  but  a  small  (|uantity  at  a  lime.  Apex  heart- 
beat now  one  and  a  half  inches  outside  left  nipple,  and  on  a  level 
with  it.  She  has  not  vomited  since  beginning  of  December. 
There  is  no  edema  of  extremities  or  other  parts  of  body,  and  has 
never  had  any  during  illness.  lias  never  exhibited  uremic 
symptoms. 

\[arch  12th.  Fearfidly  emaciated.  Can  only  rest  on  back, 
Avith  both  artns  extended  backwards  over  her  head,  her  hands 
grasping  the  iron  bars  at  head  of  the  bed.  In  this  position,  she 
seems  to  obtain  the  largest  jiossible  abdominal  and  thoracic  area 
by  protlucing  traction  upon  the  chest-walls  frotn  without.  Under 
these  circumstances,  the  heart,  and  lungs  have  more  freedom  of 
action,  and  the  patient  consequently  feels  more  comfort  than  in 
any  other  ])osition  No  further  (dumge  took  i)lace  until  the  Dith, 
Avlien  death  occurred  from  asthenia. 

Antopuji. — Dr.  Osier's  Keport:  The  body  Avas  greatly  emaci- 
ated; abdomen  distended;  superficial  veins  not  much  dilated. 
When  opened,  a  large  tumor  was  seen  tilling  the  greater  part  of 
the  abdominal  cavity,  aiul  closely  attached  to  the  right  side.  The 
omentuu  was  adherent,  the  cecum  attached  to  the  lower  end,  and 
the  ascending  colon  |)assed  along  the  left  border.  The  pylorus 
lay  upon  the  upper  end,  and  the  duodenum  was  flattened  u])on 
the  left  side  of  the  mass.  The  tumor  was  retroperitoneal,  and 
peeled  out  easily,  bringing  with  it  aorta  and  inferior  cava,  which 
were  deeply  imbedded  in  the  hiiuler  ])art.  The  mass  had  a 
rounded  outline,  broad  above,  with  a  concave  left  border,  which 
presented  several  very  soft  lobulated  i)ortions  overhanging  the 
groove  in  which  the  cecum  and  colon  lay.  The  right  border  was 
more  solid,  and  at  the  lower  part  showed  a  small  remnant  of  the 
kidney  surface.     The  growth  has  perforated  the  capsule,  and  pro- 


Alloway:  Primary  Cancer  of  tJic  Kidney.         7 

tectoil  in  largo,  soft  muHHOs,  some  of  which  wore  hemorrliagic. 
The  lust  inch  of  tho  iibdomiiiiil  iiortii  wiis  surrou.idwl  hy  tho 
tumor,  tlio  loft  iliao  was  pervioiis,  tiio  riglit  wan  lillod  with 
tiiromhi,  and  tho  wall  oaten  away.  Tho  inferior  cava  eould  be 
traced  in  the  inasH  for  about  an  iiicli  and  a  half,  and  just  above 
the  bifurcation  was  oblileratcul,  tlie  walls  in  close  contact. 
Soction  of  tho  nmss  showed  it  to  bo  niado  of  a  soft  cerobri- 
fortn  tissue  intcrs|)orHeil  with  cxtravasated  blood.  At  tho  right 
border  liieru  was  a  trace  of  kidney  substanco  in  tho  form  of  a 
thin  shell.  The  ureter  was  occluded.  The  pelvic  and  renal 
vessels  wore  infiltrated  with  the  neoplasm. 

On  niicros(;o|)ie  examination,  the  soft,  grayish-whito  substance 
was  found  to  be  composed  of  small  round  cells  with  but  little 
stroma.  Towards  the  right  border  of  the  nmss  where  it  was 
firmer,  the  soft  cerebriform  substance  was  inclosed  in  denser 
strands. 

liemarJcs. 

In  consifloring  lomo  of  tho  more  interesting  details  in  con- 
nection with  the  above  case,  I  think  it  wonld  bo  m^oU  to  dis- 
cuss them,  as  points  of  interest,  in  a  short  review  of  the  litera- 
ture of  the  subject  as  recorded  up  to  the  present  time. 
•  Nothing  of  any  value  was  written  upon  cancer  of  the  kidney, 
with  the  excej)tion  of  G.  Konig's  "  Treatise  upon  Diseases  of  the 
Kidney  "  in  1826,  and  that  of  Wilson,  of  London,  in  1817,  until 
after  tjie  year  1 830.  Cruveilhior  was  probably  the  tirst  writer  of 
note,  closely  followed  by  Rayer,  who  put  tho  disease  on  a  sound 
foundation.  After  this  came  the  classic  works  of  Walshe,  and 
then  of  Lebert,  who  distinguislied  so  clearly  between  primary 
and  secondary  forms  of  cancer  of  the  kidney.  Ebstein  and 
Roberts  are  also  well-known  authors  on  this  subject.  Rowe, 
of  Cincinnati,  records  a  very  interesting  case  in  the  American 
Journal  ok  Oustktrios,  April,  1881. 

Of  the  different  species  of  cancer  found  in  the  human  body, 
encephaloid  (fungus  homatodes)  is  the  one  almost  invariably 
•found  in  the  kidney.  Its  chief  physical  characters  as  a  neo- 
plasm consists  in  its  soft,  pulpy,  vascular  condition ;  it  is  fre- 
quently the  site  of  extensive  hemorrhages,  cavities  are  formed 
■  in  the  mass,  containing  large  quantities  of  blood  mixed  with 
cancerous  detritus  which  flows  freely  from  the  cavities  when 
opened  or  broken  into  during  the  post-mortem  examination. 
The  whole  organ  may  become  infiltrated  uniformly,  and  when 
it  does  so,  the  enlargement  is  regular.  But  we  also  have  the 
•formation  of  nodules  of  disease  growing  from  a  particular  part 


8 


Alloway  :  Primary  Cancer  of  the  Kidney. 


or  end  of  the  kidney,  and  encroacliing  upon  the  ground  of  a 
neighboring  organ,  which  gives  on  palpation  tlie  idea  of  an 
irregular  shaped  tumor,  and  adds  very  materially  to  the  diffi- 
culty of  diagnosis.  This  disease  always  begins  in  the  cortical 
substance,  and  gradually  inv^olves  the  pyramids.  The  whole 
growth  is  surrounded  by  and  contained  within  a  strong  fibrous 
membraL  In  about  sixty  (60)  per  cent  of  all  reported  cases, 
there  have  been  found  secondary  deposits  elsewhere.  The 
seats  of  these  deposits  have  been  the  lymphatic  glands  in  the 
hilus  of  the  kidneys,  the  vertebral,  and  mesenteric  glands. 
The  liver  and  lungs  were  also  affected,  but  not  so  often. 

In  considering  the  etiology  of  the  disease  it  is  a  remarkable 
faet  that  among  traumatisms  an  injury,  such  as  a  blow  or  fall, 
is  often  the  starting-point  in  the  history.     Chamel,  in   1829, 

-•ers  to  a  case  originating  from  a  blow,  in  which  the  anterior 
-  11  of  the  abdomen  was  destroyed  by  tlie  disease.  Bright 
gives  the  history  of  a  young  woman  who,  several  months  pre- 
vious to  her  death  from  cancer,  had  experienced  a  fall  down- 
stairs, and  dated  her  disease  from  that  time.  x\nother  case,  of 
a  boy,  who  dated  his  suffering  from  a  kick  in  the  left  side  ; 
he  afterwards  died  from  medullary  cancer  of  the  left  kidney. 
A  very  interesting  case  is  recorded  of  a  lady  who  died  of  car- 
cinoma of  the  kidney  eighteen  years  after  a  severe  fall  on  the 
stairs.  Immediately  after  the  accident,  she  had  a  severe  attack 
of  hematuria,  and  in  the  course  of  six  months  a  tumor  became 
evident  as  a  swelling  under  the  margin  of  the  right  ribs.  In 
my  own  oase  was  experienced  a  severe  fall  down-stairs,  three 
months  before  the  first  appearance  of  the  growth,  but  there 
was  no  hematuria  or  other  evidence  of  internal  injury.  Trau- 
matism may  play  a  certain  role  as  an  exciting  cause  in  theso 
cases ;  yet,  why  should  it  not  be  constant,  and  do  so  in  all 
cases ;  instead  of  which  we  have  such  injury  followed  in  one 
case  by  nephritis,  in  another  by  perinephritis,  and  another  by 
malignant  disease.  These  are  pure  clinical  facts,  inexplicable 
unless  we  fall  back  on  the  doctrines  of  individual  predisposi- 
tion. 

The  earlier  writers  looked  upon  cancer  of  the  kidney  during 
childhood  as  a  curiosity  from  its  rarity,  but  more  extended  re- 
search has  taught  us  that  it  is  found  chiefly  in  the  extremes  of 
life — earlv  childhood  and  old  ajje — \yhilft  the  periods  of  life 


\ 


Alloway  :  Primary  Cancer  of  the  Kidney.         9 

between  these  points  enjoy  a  remarkable  immunity  from  it. 
It  is  said  that  males  are  more  prone  than  females — of  twenty- 
four  children  fifteen  were  boys  and  nine  girls,  and  the  dis- 
parity is  still  greater  with  adults.  This  disproportion  may  be 
accounted  for  by  tlie  marked  preference  shown  by  cancer  for 
the  organs  of  generation  in  the  female. 

In  cancer  of  the  kidney,  tliere  are  two  distinct  symptoms 
almost  always  met  with — an  aldominal  tumor  and  hematuria. 
Roberts  asserts  that  in  all  fatal  cases  one  or  both  of  these 
symptoms  are  invariably  present.  Of  sixty-four  cases  sixty- 
one  had  a  large  abdominal  tumor,  and  tlie  remaining  three  had 
hematuria ;  and  it  is  noteworthy  that  in  all  children  who  have 
died  from  this  disease  there  was  an  enormous  abdominal  tumor 
present.  These  tumors,  as  a  rule,  represent  the  largest,  as  a 
variety,  which  are  met  witli  in  children.  They  begin  in  the 
loins  between  the  ribs  and  the  crest  of  the  ilium,  they  increase 
Yi  upwards  and  downwards,  and  to  the  front  towards  the  navel. 
Percussion  within  this  area  elicits  a  dull  note,  provided  there 
is  not  part  of  the  intestine  between  tlie  tumor  and  the  abdominal 
wall.  But,  as  a  rule,  this  is  the  case  ;  and  in  the  case  of  the 
right  kidney  being  affected,  the  ascending  colon  and  cecum 
are  generally  found  on  the  outer  side  of  the  tumor,  and  as  the 
growth  enlarges,  the  ascending  colon  is  pushed  forward,  and  is 
found  running  obliquely  across  the  growth  from  right  to  left. 
Here,  of  course,  we  would  get  a  clear  tympanitic  note. 

In  my  case,  the  bowel  ran  along  on  the  left  side  of  the 
growth  in  its  entire  length,  and  at  no  place  crossed  it.  There- 
fore, there  was  an  important  diagnostic  sign  wanting,  though, 
towards  the  end,  such  a  displacement  of  the  bowel  was,  how- 
ever, considered  possible,  and  would  account  for  the  uninter- 
rupted dull  note  obtained.  In  the  case  of  the  left  kidney  when 
it  is  affected,  the  same  condition  obtains.  Here  the  descending 
colon,  and  often  part  of  the  small  intestines,  cross  or  lie  right  in 
.front  of  the  tumor,  separating  it  from  the  abdominal  wall.  It 
is  quite  true,  however,  that  the  intestines  can  cross  the  tumor 
and  still  elicit  a  dull  note  on  percussion,  from  the  tact  of  it 
being  so  compressed  that  it  becomes  a  mere  flattened  band,  and 
in  some  cases  has  been  felt  as  such  through  the  abdominal 
walls.  These  tumors  are  genernlly  lirmly  flxed  by  adhesion, 
and  are  not  intinenced  by  the  movement  of  the  diapliragm. 


10       Alloway  :  Primarij  Cancer  of  the  Kidney. 

In  my  case,  however,  the  tnrnorwas  remarkably  movable,  both 
by  palpation  and  the  action  of  the  diaphragm  during  respira- 
tion, without  causing  the  patient  pain  or  inconvenience.  This 
point  is  important,  from  the  fact  that  there  is  a  case  reported 
in  the  London  Lancet  (March  18th,  1865),  in  which  the  dis- 
eased kidney  was  so  movable  or  wandering  that  it  was  taken 
for  an  ovarian  tumor.  The  usual  elasticity  of  these  growths 
on  palpation,  amounting  sometimes  to  a  sense  of  fluctuation, 
carries  with  it  a  deception  for  which  we  cannot  be  too  much 
"  upon  our  guard  "  in  making  a  diagnosis.  It  is  probably  con- 
veyed to  the  hand  by  the  general  softening  process  taking  place 
in  the  growth  as  it  enlarges,  and  by  the  formation  of  secondary 
cysts  or  cavities,  chiefly  on  the  surface  of  the  principal  growth, 
filled  with  a  semi  fluid  cellular  substance  which  is  capable  of 
conveying  a  wave-like  impression  on  palpation. 

We  come  now  to  a  very  interesting,  and  I  may  say  almost 
unique,  symptom  in  the  case  ;  a  loud  blowing  systolic  murrmir 
heard  all  over  the  tumor.  This  phenomenon  first  attracted  my 
attention  about  the  end  of  the  third  week  of  attendance,  when 
the  tumor  was  still  hard.  It  continued  to  be  audible,  though 
gradually  fading  in  intensity,  until  the  tumor  became  soft  and 
fluctuating,  when  it  disappeared  altogether.  Its  disappearance 
at  this  time  was  probably  due  to  the  non-transmission  of  sound 
through  so  extensive  a  semi-fluid  mass,  as  there  was  certainly 
no  evidence  of  the  complete  occlusion  of  the  main  vessel. 
This  symptom  we  must  regard  as  one  of  peculiar  interest.  To 
judge  it  from  first  impressions  occurring  to  an  observer  not 
over  cautious  in  giving  an  opinion,  it  would  very  probably  be 
diagnosticated  as  an  aneurism  of  one  of  the  abdominal  vessels, 
and  I  think  the  error  would  bear  some  fairly  pardonable  fea- 
tures in  it.  Ballard  reports  a  case  in  Transactions  of  Patho- 
logical Society,  1859,  in  which  the  murmur  was  so  loud  that  it 
was  diagnosed  as  an  aneurism  of  the  renal  artery.  Jiristow 
also  reports  a  case  {Med.  2'imes  and  Gaz.^  1854,  ii.,  395)  in 
which  a  similar  phenomenon  was  present.  It  may  be  remarked, 
however,  that  in  each  of  the  above  instances  there  was  also  a 
distinct  pulsation,  which  could  not  be  obtained  in  this  case. 
The  direct  cause  of  this  murmur  is  ditticult  to  decide  upon.  It 
may  be  duo  to  direct  pressure  upon  the  aorta,  or  from  the  blood 
current  acting  upon  a  partially  occluding  thrombus  situated  on 


ALLOWA.Y :  Primary  Cancer  of  the  Kidney.       1 1 

the  wall  of  the  vessel.  If  these  views  are  correct  one  would 
expect  to  have  this  symptom  more  often  recorded  than  it  has 
heen,  and  probably  it  would  have  been  were  it  more  carefully 
looked  for  at  the  beginning  of  tiie  disease. 

"We  now  come  to  the  consideration  of  the  other  distinctive 
symptom,  hematuria.    It  will  be  remembered  that,  although  the 
most  careful  investigation  was  made  in  regard  to  this  symptom, 
it  never  occurred  from  first  to  last.     This  is  important  from  the 
fact  that  the  patient's  illness  dated  from  a  severe  fall  with  di- 
rect injury  to  the  right  loin;  and  that  in  about  fifty  per  cent 
of  all  cases  reported,  hematuria  was  noticed  at  some  period  of 
the  illness.     In  the  cases  which  received  direct  violence  to  the 
part,  the  hemorrhage  was  generally  noticed  at  the  time  of  the 
accident,  and  lasted  in  some  cases  but  a  short  while,  and  not 
reappearing  before  death.     Then  again  it  may  be  intermittent, 
appearing  for  a  few  days,  disappearing,  and  then  in  a  few  days 
reappearing  again.     In  other  cases  again,  it  does  not  appear 
until  within  a  few  weeks  of  death.     When  hematuria  is  noticed 
in  the  early  stages,  it  is  undoubtedly  a  sign  of  great  value,  and 
should  give  us  food  for  thought;  but  it  must  not  be  forgotten 
that  it  is  also  present  in  other  diseases  of  tiie  urinary  tract. 
It  may  also  be  present  with  a  tumor  in  the  left  side  and  not 
be  due  to  renal  cancer,  for  profuse  hematuria  often  occurs  in 
leukfBinic  patients.     When  hematuria  is  absent  it  is  tiionght 
to  be  due  to  complete  occlusion  of  the  ureter  of  affected  kid- 
neys, either  by  pressure  or  by  extension  of  the  disease  into  it. 
In  Van  Denburg's  case  (Am.  Journal  of  Obst.,  October,  1881, 
593),  the  urine  was  free  from  blood  and  other  abnormal  ingre- 
dients throughout  the  entire  period  of  disease.     This  case  of 
Van  Denburg's,  I  may  remark  in  passing,  teaches  us  a  very 
important  lesson  in  another  respect,  namely,  the  necessity  for 
giving  very  guarded  opinions  in  respect  to  these  abdominal 
tumors  in  children.     His  first  consultant  declared  emphatically 
that  it  was  a  case  of  hepatitis,  "just  as  sure  as  if  he  had  the 
liver  in  his  hand."     Further  council  decided  it  was  a  case  of 
nonmaligiiant  tumor  of  a  cystic  nature.    Paracentesis  was  per- 
foriuod,  withdrawing  six  to  eiglit  ounces  of  albuminoid  fluid. 
llooklets  of  the  ecchinococcus  could  not  he  found.     Again  fresh 
council  was  obtained,  and  a  larger  needle  used  under  chloro- 
form,  which  resulted  in  the  diagnosis  of  "  multiple  cystic  ta- 


12 


Alloway:  Primary  Cancer  of  the  Kidney. 


raor.''  Tlie  patient  died,  and  at  the  autopsy  it  turned  out  that 
the  liver,  which  was  accused  of  being  tlie  cause  of  all  the 
trouble  in  so  many  different  ways,  and  by  so  many  experienced 
^\^s^no%t\^i\M^&,wa8  perfectly  healthy,  and  that  that  little  deceiv- 
ing neighbor  of  it,  the  kidney,  was  tlie  organ  at  fault. 

The  reaction  of  tiie  urine  in  my  case,  it  will  be  remembered,, 
was  normal,  as  it  generally  is  in  these  cases,  except  when  ad- 
mixed with  blood,  and  then,  as  a  matter  of  course,  we  got  albu- 
men.    But  albuminuria  without   hetnaturia  is  rare,  pyuria  and 
nephritis  being  excluded.    Uremic  symptoms  are  also  exceed- 
ingly rare,  for  the  obvious  reason  that,  so  long  as  the  other  kidney 
remains  healthy,  there  can  be  no  retention  in  the  blood  of  the 
poisonous  constituents  of  the  urine,  which  it  is  the  function  of 
the  kidneys  to  excrete.     Tlie  urine  in  this  case  was  not  exam- 
ined microscopically,  it  being  well  known  that  as  an  aid  in 
the  diagnosis  of  cancer  it  is  of  uncertain  and  questionable  re- 
liability.    Moore  records  a  case  {Medico- Ohirg.  Trans.,  xxxv.),. 
in  which  he  found  roundish  caudate  cells,  and  in  many  other 
recorded  instances  of  the  discovery  of  cancer  cells  there  is  no 
proof  of  the  supposed  cancer  elements  being  other  than  epithe- 
lial cells  from  the  renal  pelvis  and  ureters.     Halle  states  that 
in  a  few  instances  of  renal  cancer,  he  has  found  deposits  of  uric 
acid  as  well   upon  discharged  flocculi  of  cancer  tissue,  as  up- 
on the  waste  substances  obtained  at  the  autopsy.     But  the  dis- 
covery of  certain  cell-forms  in  the  urine  is  of  no  value  in  the 
diagnosis  of  cancer.     The  symptom  which  can  only  be  recorded 
as  signitieant  is  tlie  discovery  of  cancer  particles  with  an  al- 
veolar strxicture.     Roberts  says  :     "  It  must  be  remembered 
that  cancer  cells  which  would  find  their  way  into  the  urine 
must  have  come  from  broken  down  and  degenerated  parts  of 
the  growth,  and  to  identify  them  in  their  changed   condition 
is  more  than  he  has  ever  been  able  to  accomplish." 

A  symptom  very  variable  in  its  degree  of  intensity  is  pain. 
In  this  case  it  never  amounted  to  more  than  that  which  v/ould 
cause  the  patient  to  say  "  my  belly  is  sore."  In  some  cases, 
hovvever,  it  is  described  as  being  agonizing;  while  in  others 
again  it  has  been  entirely  wanting  until  near  the  end.  Its  ab- 
sence, however,  is  not  of  sufHcient  significance  to  exclude  the 
existence  of  renal  cancer. 

Gastric  symptoms  are  generally  prominent.      In  this  case 


Alloway:  Primary  Cancer  of  the  Kidney.       13 

there  had  been  nausea  and  vomiting  in  the  beginning  of  the 
disease,  b\it  after  it  ceased  it  did  not  return.     In  some  cases  tlie 
appetite  is  voracious,  accompanied  with  increased  thirst.     In 
this  case  tliere  was   anorexia  from  tiie  beginning  to  the  end. 
Tiiere  was  no  jaundice  or  tinting  of  the  skin  of  any  nature.* 
No  anasarca  which  might  be  expected  witii  thrombosis  of  the 
vena  cava;    probably  the  compensatory  circulation  of  there- 
turn  blood  tlirougli  the  extensive  anastomosis  formed  by  the 
superficial  cutaneous  veins  prevented  its  occurrence.     In  re- 
marking upon  the  duration  of  the  disease,  it  may  be  said  that 
it  is  much  shorter  in  children  tlian  in  adults.     But  it  is  exceed- 
ingly difficult  to  be  definite  upon  this  point,  as  the  beginning 
of  the  disease  cannot  be  fixed  with  certainty.     In  very  debili- 
tated  children  a  few  weeks  may  see  the  end,  while  in  others, 
six  to  thirteen  months.     Ebstein  says  he  has  seen  but  one  case 
of  cancer  of  the  kidney  in  a  child  which  lasted  as  long  as  two 
jears.     It  is,  however, erroneous,  as  maintained  by  Walshe  and 
Lebert,  that  the  renal  cancer  runs  a  more  rapid  course  than 
other  visceral  cancers.     The  contrary,  in  fact,  is  established, 
namely,  that  as  a  rule  death  is  longer  delayed  in  renal  cancer 
than  in  primary  cancer  of  any  otiier   internal  organ.     The 
mean  duration  of  cancer  of  the  pylorus,  of  the  liver,  lung,  or 
brain  is  under  thirteen  months,  or  thereabout.     This  tolerance 
on  the  part  of  the  kidney  may  be  accounted  for  by  the  dupli- 
cation of  the  organ ;   when  one  kidney  becomes  disabled,  the 
other  takes  on  a  compensatory  hypertrophy,  and  does  tlie  work 
of  its  diseased  fellow.     The  advantage  of  much  room  being  af- 
forded the  enlarging  organ,  in  virtue  of  its  situation,  is  also 
obvious. 

As  the  prognosis  of  tliis  disease  is  decidedly  bad,  invariably 
fatal,  the  treatment  consists  in  the  employment  of  sucli  thera. 
peutic  measures  as  will  tend  to  relieve  distressing  symptoms.' 
I  may  say  that  the  removal  of  cancerous  kidney  is  a  procedure 
which  I  don't  think  is  regarded  as  sound  by  scientific  surgeons. 
Walcott  extirpated  a  cancerous  kidney  which  he  had  taken  for 
a  hepatic  cyst;  the  growth  vveighed  two  and  a  half  pounds,  and 
the  patient  survived  the  operation  just  two  weeks. 


